93 Decision Citation: BVA 93-19723
Y93
BOARD OF VETERANS' APPEALS
WASHINGTON, D.C. 20420
DOCKET NO. 92-23 197 ) DATE
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THE ISSUES
1. Entitlement to service connection for residuals of injuries
to the right middle finger.
2. Entitlement to service connection for bilateral knee injury
residuals.
3. Entitlement to service connection for bilateral ankle injury
residuals.
4. Entitlement to service connection for headaches and
blackouts.
5. Entitlement to service connection for an acquired
psychiatric disorder characterized by anxiety and depression.
6. Entitlement to service connection for a disorder
characterized by chest pain.
7. Entitlement to service connection for hearing loss.
REPRESENTATION
Appellant represented by: Charles Stein, Attorney-at-law.
WITNESS AT HEARING ON APPEAL
The appellant
ATTORNEY FOR THE BOARD
Siobhan Brogdon, Counsel
INTRODUCTION
This matter came before the Board of Veterans' Appeals from a
rating decision of April 1992 from the Newark, New Jersey
Regional Office (hereinafter RO). The veteran served on active
duty from January 1989 until September 1991. The notice of
disagreement was received in June 1992. The statement of the
case was issued in September 1992. The substantive appeal was
received in November 1992. The claims folder was received and
docketed at the Board in December 1992. The veteran was
afforded a personal hearing before a member of the Board sitting
at Washington. D.C. in March 1993. He is represented in this
matter by Charles Stein, Attorney at law. The case is ready for
appellate review.
REMAND
The veteran asserts that he now has multiple physical conditions
as the result of active duty as well an anxiety and depressive
disorder, chest pain and headaches from his service in the
Persian Gulf. During his personal hearing, he testified that he
had begun to experience nervousness while being deployed in the
Gulf because of the harsh physical environment and because he
initially did not know what was going to happen to him. He
indicated that such symptoms also became manifest as the result
of engaging in several hours of actual combat against the enemy.
He stated that since his return from the Middle East, he had
begun to have increased symptoms of nervousness, as well as
frequent nightmares, dizziness, blackouts, headaches and chest
pain which he believed were intertwined and stemmed from the
Desert Shield/Storm experience. The veteran has submitted a
statement from a private physician rendering a diagnosis of
severe post-traumatic stress disorder with psychophysiological
stomach disorder, chest pain, heart palpitation, headaches, easy
fatigability and a severe depressive reaction causally related
to the Gulf war.
During his testimony, the veteran also said that he had been
seen at a Department of Veterans Affairs (VA) facility in East
Orange, New Jersey after service for psychiatric symptoms and
had been given a prescription for Vistaril/hydroxyzine. He
related that he had been treated by several providers over the
years before service, including the Somerset Pediatrics Group
and the St. Peters Medical Center, and since service at the VA
and Hadley Primary Medical Center for various complaints and
disorders. These records have not been requested or secured.
The Board also notes in this regard that the veteran's 201 file
folder has not been made available for review.
The VA has a duty to assist the veteran in the development of
facts pertinent to his claim. This duty includes securing
medical records to which reference has been made and obtaining
adequate VA examination. Under the circumstances of this case,
we are of the opinion that additional assistance is required.
The case is therefore REMANDED to the RO for the following:
1. The veteran should be requested to
sign and submit consent forms for the
release of all of his clinical records
from the cited medical providers above.
The medical data should then be requested
and associated with the claims folder.
2. The veteran's 201 file folder should
be requested and associated with the
claims folder.
3. Any and all of the veteran's clinical
records at the East Orange, New Jersey VA
facility should be requested and
associated with the claims folder.
4. The veteran should be scheduled for
another VA special psychiatric evaluation
by an examiner who has not seen him
previously to determine the nature and
extent of any psychiatric disorder now
indicated. All necessary tests and
studies, including psychological testing,
should be accomplished, and clinical
manifestations should be reported in
detail. The claims folder should be made
available to the examiner prior to
evaluation. The examiner should refer to
Chapters 14 and 20 of the Physician's
Guide for Disability Evaluations
Examinations. Special attention should be
directed to the diagnosis of post-
traumatic stress disorder made in this
case, particularly whether any current
findings and symptoms fall within the
diagnostic criteria set forth for that
disorder. The examination report should
be typed.
Following completion of these actions, the agency of original
jurisdiction should review the evidence and determine whether
the veteran's claim may now be granted. If not, the veteran and
his representative should be provided with an appropriate
supplemental statement of the case and the case should be
returned to the Board for further appellate consideration.
Adjudication of all other issues on appeal will be deferred
pending completion of the above.
BOARD OF VETERANS' APPEALS
WASHINGTON, D.C. 20420
*
B. KANNEE
ALBERT D. TUTERA
*38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board of
Veterans' Appeals Section, upon direction of the Chairman of the
Board, to proceed with the transaction of business without
awaiting assignment of an additional member to the Section when
the Section is composed of fewer than three Members due to
absence of a Member, vacancy on the Board or inability of the
Member assigned to the Section to serve on the panel. The
Chairman has directed that the Section proceed with the
transaction of business, including the issuance of decisions,
without awaiting the assignment of a third Member.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Veterans Appeals. This remand is in the nature of a
preliminary order and does not constitute a decision of the
Board on the merits of your appeal. 38 C.F.R. § 20.1100(b)
(1992).